Snowboard wrist guards-use, efficacy, and design: a systematic review.
Abstract: The popularity of snowboarding has brought awareness to injuries sustained during the sport. Wrist injuries are among the most common injuries, and there is an interest in using protective equipment to prevent these injuries. The purpose of this study was to review the literature on wrist guard use, injury prevention, the biomechanical effects of wrist guards, and the various types of wrist guards commercially available for consumers. A literature search was done using MEDLINE[R] Ovid (1950 to January 2009), MEDLINE[R] PubMed[R] (1966 to January 2009), and EMBASE[R] (1980 to January 2009) for studies on snowboard injuries and wrist guards. References from the studies found were also reviewed. Two randomized controlled studies (Level I), one meta-analysis (Level II), eight prospective case control studies (Level II), one cross-sectional study, and four biomechanical-cadaveric studies were found from the literature search. Based on the review of this literature, wrist injuries are among the most common injury type, and wrist guard use may provide a protective effect in preventing them. There is no consensus as to what type or design of wrist guard is the most effective and which wrist guards are available for use by the consumer.
Article Type: Report
Subject: Snowboards and snowboarding
Safety equipment
Authors: Kim, Suezie
Lee, Steve K.
Pub Date: 04/01/2011
Publication: Name: Bulletin of the NYU Hospital for Joint Diseases Publisher: J. Michael Ryan Publishing Co. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 J. Michael Ryan Publishing Co. ISSN: 1936-9719
Issue: Date: April, 2011 Source Volume: 69 Source Issue: 2
Accession Number: 289120438
Full Text: Snowboarding is one of the fastest growing winter sports, with 2008 statistics showing the number of snowboarders to be 5.9 million, compared with 6.5 million alpine skiers, in North America. (1) The rising popularity of extreme sports and high profile snowboard events, such as the Olympics, X-Games, and the U.S. Open, has helped to catapult participation of this winter sport. With the increase in popularity, a number of articles in the recent literature have tackled the topic of snowboard-related injuries. Various types of studies, including prospective-retrospective case series, case reports, and case controls on snowboarding injuries, can now be found in the literature. Many investigations have found that snowboarders sustain a high number of upper extremity injuries, especially when compared with skiers. (2-6) Matsumoto and colleagues (5) found that among injured snowboarders, 40% sustained upper extremity injuries, while only 19% of skiers did (p < 0.0001). Multiple other studies have found that wrist injuries, in particular, are prevalent upper extremity injuries. (4,5,7-20) The population most at risk for this type of injury is beginner snowboarders. (2,8,21,22) The increased risk of wrist injury can be attributed to the typical mechanism of a fall when riding a snowboard. The equipment used in snowboarding consists of the rider strapping in both feet to a board with bindings that do not release during a fall. When the rider loses balance, instinctively they fall with their arm stretched out, putting the participant at increased risk of sustaining an upper extremity injury.

Protective equipment may play an important role in the prevention of wrist injuries. Specifically, wrist guard use has been advocated by authors of multiple papers. (2,13,23,24) Russell and coworkers (25) did a meta-analysis on this topic, but only evaluated the reduction of wrist injuries with wrist guard use. The purpose of this study is to review the literature on wrist guard use, injury prevention, the biomechanical effects of wrist guards, and the specific design of wrist guards.

Materials and Methods

A literature search was conducted using the computerized literature databases MEDLINE[R] Ovid (1950 to January 2009), MEDLINE[R] PubMed[R] (1966 to January 2009), and EMBASE (Excerpta Medica Database) (1980 to January 2009). Databases were searched using the keywords "snowboard," "wrist injuries," "upper extremity," "wrist splint," "wrist brace," and "wrist guard." References from the articles were also reviewed for inclusion.

After reviewing all of the articles obtained through the searches, studies were included if they involved snowboard data collection on wrist guard use, injuries sustained due to wrist guard use, evaluated injury prevention-efficacy of wrist guards in snowboarding, cadaveric, or biomechanical studies on wrist guards.

Results

Sixteen studies were found in the literature search that included information on wrist guards with the above mentioned inclusion criteria.

Prospective Randomized Controlled Trials (Level I)

Two randomized controlled trials (RCT) were found in the literature search (Table 1). Machold and associates (24) conducted a study of 721 Austrian students (mean age, 15 years) who snowboarded as part of their winter sport vacation; 342 participants were randomly assigned to the protected group, and 379 were assigned to the control, or unprotected, group. The protected group wore a wrist guard that was designed specifically for the study; it was palmar in location, curved at the area of the carpus, the distal end did not exceed the proximal flexion crease of the hand, and it had an extension of the palmar support to the forearm. Injuries were classified according to the Abbreviated Injury Scale (minor: contusion or sprain, or both; moderate: nondisplaced fracture or epiphysiolysis of radius; severe: displaced fracture). The incidence of severe wrist injury was 1 of 342 snowboarders (0.0029) in the protected group and 9 of 379 snowboarders (0.023) in the unprotected group. There was a decrease in risk by a factor of 0.13 using the wrist guard (p = 0.05).

Ronning and colleagues (22) studied 5029 snowboarders at the Hafjell Alpine Center in Norway. They randomized 2515 to the braced group and 2514 to the control group. The randomly assigned braced group used a D-ring wrist brace with an aluminum splint on the volar side (Smith & Nephew, Nesbru, Norway). Both groups were evaluated for an end point of wrist fracture or sprain; 29 (1.2%) of the unprotected group sustained wrist injuries, compared with 8 (0.3%) of the protected group (p = 0.001).

Meta-Analysis (Level II)

One study was found that reviewed the literature to examine the effectiveness of wrist guards in preventing wrist injuries in snowboarders (Table 2). Russell and coworkers (25) found six studies that demonstrated a comparison between wrist guard snowboarders and unguarded snowboarders and the wrist injuries sustained. They concluded that based on the literature search, wrist guard use did significantly reduce the risk of wrist injury. The investigators did note that due to the various wrist guards that were used in all of the included studies, no particular wrist guard was deemed optimal to reduce the number of wrist injuries.

Prospective Case Control Studies (Level III)

Eight prospective case studies were found in the literature search (Table 3). A case control study was performed in 20 large ski areas in Quebec, Canada by Hagel and associates. (23) The case group consisted of 1066 persons, who sustained an upper extremity injury. The control group included 970 injured snowboarders, who sustained injury to a body region other than the upper extremity. The prevalence of wrist guard use among snowboarders with upper extremity injuries was 1.6%, compared with 3.9% in snowboarders with other injuries. There was no mention of the brand of wrist guards used by participants in the study. Upper extremity injuries included bruises, dislocations, fractures, and sprains. It was found that wrist guard use reduced hand-forearm wrist injury by 85% (95% CI, 0.05-0.45). Injuries to the elbow-shoulder were found to be increased two-fold, but were not significant (95% CI, 0.70-7.8; p = 0.17).

Upper extremity snowboard injuries were also studied by Idzikowski and colleagues (13) in Colorado. The study involved 10 seasons (1998-1998) and included injured snowboarders who sought medical treatment in 47 medical facilities near Colorado ski resorts. The study consisted of 7430 snowboard injuries and 3107 non-injured snowboarders as a control group. The characteristics of the control group were obtained from the 1995 and 1996 Ski Industries of America Snowboard Survey and the 1994 Canadian Ski Council National Snowboard Survey; 5.6% of the injured group wore wrist guards (no specific brands listed). The control group did not have information related to the use of wrist guards. Wrist injuries were defined as fractures, dislocations, sprains, and contusions; 21.6% of all injuries were wrist injuries. Injured snowboarders without wrist guards were twice as likely to be seen for a wrist injury as those who wore them (p = 0.0001).

First-day injuries among skiers, snowboarders, and skiboarders in Scotland were assessed by Langran and Selvaraj. (26) Injured participants at Cairngorm, Glenshee, and Nevis Range ski areas, during three winter seasons (1999-2002), who were evaluated by the ski patrol or those who presented to Aviemore Medical Practice, were included in the study; some subjects were seen by both. The data included 2124 injuries and 1782 control participants. Demographics and injury information data were obtained. Control data was collected by face-to-face interviews on a variety of days and times. In the injured population, no wrist guards were worn among the first-day participants, while 1.3% of all injured snowboarders wore them (p = 0.305). There was no mention of the specific types of wrist guards that were worn. Injuries sustained by the participants were categorized as fracture, laceration, sprain, dislocation, subluxation, or bruising. The most common injury location among snowboarders was the wrist, 33.3% among first-day participants and 21.2% among all others.

Machold and associates (15) also performed a controlled case study with a similar population of Austrian students as the prospective randomized controlled trial (24) mentioned in the previous section. A total of 2579 snowboarders were included in the study during one snowboard season 19961997; 152 injured snowboarders were evaluated. A total of 39% (999 snowboarders) wore wrist guards. There was mention of multiple gloves, with integrated wrist guards available on the market, but none were specified in association with injuries. Wrist injuries were defined as minor (sprains-contusions), moderate (fractures of the radius), and severe (displaced fractures of the radius); 32.2% of all injured snowboarders had a lower arm-wrist injury. Lack of use of wrist guards increased risk of injury by 2.78 (95% CI, 1.05-7.35; p = 0.039).

Made and Elmqvist (16) conducted a 10-year study of snowboard injuries in Lapland, Sweden, at Tarnaby and Hemavan ski resorts; 568 injured snowboarders were included in the study. An injury form that included demographics, circumstances surrounding the injury, previous injuries, and snow conditions was completed by the patients and the physician. The control group was based on interviews of uninjured participants on the slopes, and the same form was used to collect data. Eleven percent of the injured snowboarders wore some kind of wrist guard (no specific brand mentioned). Wrist guard use was more prevalent in the advanced group (19%), compared with the intermediate group (10%) and the beginner group (7%). Injuries were defined as fractures, contusions, sprains, dislocations, lacerations, and other. Thirty-five percent of all snowboard injuries involved the lower arm-wrist.

Matsumoto and coworkers (5) conducted a prospective comparative study of upper extremity injuries sustained between 1995-2000 and presented to Sumi Memorial Hospital, the only emergency hospital covering more than 10 skiing facilities; 6837 snowboard injuries were included in the study, compared to 3 million snowboard participants in the control group (based on number of passes sold). All injured participants were asked to fill out a questionnaire, including use of protective equipment; however, there was no mention about which types of equipment were used (i.e., wrist guard, helmet, etc.). Among the participants who had upper extremity injuries, protective equipment was worn by 13%, as compared to 87% without. The most common location of snowboard injury was the upper extremity, 40%, compared with 19% in skiers (p < 0.001). When comparing all the fractures sustained by snowboarders in the upper extremity, 62% were fractures of the wrist.

O'Neill (27) conducted a prospective control trial in the White Mountains of New Hampshire. All included participants were involved in the "Learn to Snowboard" program, where rental equipment, line ticket, and a 2-hour lesson was part of the package. This study was conducted during two winter seasons (1998-2000). The total number of participants was 2355, of which 551 were in the wrist guard group, and 1804 were in the control group. All participants were offered a wrist guard (Seneca Sports Inc., Milford, Massachusetts), and those who refused were put in the control group. Wrist injuries included sprains (soft tissue swelling in the area of wrist, with pain significant enough to seek medical attention) and fractures; 2.2% of the unprotected group sustained wrist injuries, compared with 0% in the group with wrist guards (p < 0.001).

Slanely and associates (28) did a case control study from Mount Buller Medical Center, Victoria, Australia, during one snowboard season; 119 injured snowboarders seen at the clinic with a fractured wrist were included. The control group included the people wearing snowboard boots in the clinic as patients or as companions. Injured snowboarders with wrist fractures numbered 119 and the control group 375; 15% of snowboarders with wrist fractures wore wrist guards, whereas 20% of the control group wore wrist guards. Use of wrist guards demonstrated a 42% reduction in wrist fracture but was not statistically significant (OR, 0.58; 95% CI, 0.32-1.04; p = 0.07). No particular wrist guard brand was mentioned in the study. Twenty-four percent of all the snowboarders included in the study acquired wrist fractures.

Cross-Sectional Survey

Kroncke and colleagues (29) surveyed the use of protective equipment among adolescent in-line skaters, skateboarders, and snowboarders in central southeast Wisconsin, from August 2003 to March 2004. A total of 226 of the 333 surveyed were adolescent snowboarders (Table 2); 16.7% of the snowboarders stated that they used wrist guards. Participants were not asked about specific brands of wrist guards used. Parents were the most common reason for the use of any protective equipment (35%), while other factors, such as rule-requirement (23%), friends (20%), sibling (5%), coach (4%), celebrity-advertisement (3%), and physician (3%) were also mentioned.

Biomechanical and Cadaveric Studies

Four biomechanical studies were found in the literature search relevant to the evaluation of wrist guards as protective apparel (Table 4). Greenwald and coworkers (30) performed a cadaveric study with wrist guards. Twelve arms from six fresh-frozen cadavers were used. Each specimen was mounted to a drop fixture (guillotine-type track), which was positioned above a force platform (AMTI Corp., Watertown, Massachusetts). The arms were randomly assigned to a wrist guard constructed of Kydex[R] (Kleerdex Co. LLC, Mount Laurel, New Jersey), with a ventral splint from the metacarpophalangeal joint to the mid-forearm and strapped with three Velcro[R] straps (Velcro[R] USA, Inc., Manchester, New Hampshire). The specimen was dropped from a 40 cm height onto the force platform. The braced group had a higher impulse (change in momentum) applied by the force platform to the drop complex before failure (p < 0.01). It was noted that the greatest reduction in momentum was during the first two loading phases in the vertical force platform. This suggests that the brace was not useful in reducing momentum after a certain amount of force. The study concluded that the wrist guard used may have some prophylactic effect in low energy falls, but not at higher loads.

A biomechanical human subject study was performed by Hwang and associates. (31) The experiment consisted of 30 young adults; each subject had two trials, randomized with and without wrist guards. The wrist guards used in the study were Bone Shieldz (Litchfield, Illinois). A landing pad with a force transducer was mounted on an inclined wall (20[degrees] from vertical) in front of the subject. A cable was used to hold the subject leaning 10[degrees] forward or backward and was randomly released. The subject stopped the fall with outstretched arms onto the landing pad, from which impact and braking forces were measured. It was found that wrist guard use had a significant change in only the impact force parameters of the backward fall. The investigators concluded that the wrist guards did not provide statistically significant reduction of maximum force transmission.

Kim and colleagues (32) designed a biomechanical study with a mechanical surrogate. The surrogate was the forearm hand complex of an enhanced airbag interaction (EAI) arm. The surrogate was tested under five different conditions: 1. bare, 2. UltraWheels wrist guard (First Team Sports, Inc., Anoka, Minnesota); 3. Sorbothane glove (ER-502, Ergotech Canada Inc, Ontario, Canada); 4. air cell simple pneumatic spring mechanism harvested from a pneumatic armband (Aircast Inc., Summit, New Jersey); and 5. an "air bladder" (Dielectrics Industries Inc., Chicopee, Massachusetts). The force was measured with a six-channel forearm load cell and a commercial force plate (Type 4600-10, Bertec, Columbus, Ohio). The surrogate was mounted on a guillotine-style platform and was dropped in full extension at four different heights (13 cm, 25 cm, 38 cm, 51 cm) onto an aluminum block (ensuring palmar impact) and force plate. It has been reported that the force for fracture of the radius is 2245 N. The peak impact forces were smaller in all of the padded conditions, compared with the bare hand condition (p < 0.05). The air bladder maintained forces below the peak of 2245 N at all falling heights, while the rest of the protective devices became ineffective at various heights. The wrist guard became ineffective at a height of 51 cm. The investigators concluded that wrist guards may be effective, but may not be protective in all the various types of impacts in different sporting activities. It was criticized that common wrist guards are made of rigid splints and do not absorb and store energy sufficiently. They suggested a wrist guard design with a pneumatic spring mechanism and more padding to provide more shock absorption and increase fracture strength.

A cadaveric study was done by Staebler and coworkers (33) to determine the effect of wrist guards on bone strain. Three pair of fresh-frozen cadaveric upper extremities were used. Each specimen was tested unguarded and with two different wrist guards. Guard A was the Bone Shieldz wrist guard, which had a wraparound design, with the volar splint elevated off of the wrist. Guard B was the Rollerblades wrist guard (Minnetonka, Minnesota) with a slip-on design, where the volar plate was not elevated. A servohydraulic materials testing machine was used to apply load onto the specimen at the volar pole of the scaphoid and the load surface (volar angle where the guard would be in contact with the surface). Strain gauges were attached to the distal radius (both volar and dorsal), the volar radial shaft, and the dorsal distal ulna. With wrist guard A, the strain in the dorsal distal radius was 46% less than with the unguarded specimen, compared with 23% lower with wrist guard B (p < 0.05). The strain on the volar distal radius was 80% lower with wrist guard A (p < 0.05) versus 30% lower with wrist guard B (not statistically significant). Only wrist guard A showed a decreased strain in the dorsal and volar midshaft (61% and 44% respectively).

Discussion

The growing popularity of snowboarding as a winter sport has brought attention to the injuries that can be sustained with participation. All of the studies found in the literature recognize that wrist injury is one of the most common injuries among snowboarders. The literature search demonstrated a large number of studies that advocate the use of wrist guards to prevent lower arm-wrist injuries.

Several studies found that beginners injured their wrists more often than higher-level snowboarders. This can be explained by the fact that beginners are more likely to fall, especially during the early part of their snowboard participation. First-day participants were noted to have a higher prevalence of wrist injuries when compared with all other snowboarders. (26) Without proper education on how to fall, beginners will instinctively fall with their arms outstretched. This mechanism is classic for distal forearm-wrist injury. As a snowboarder becomes more advanced in the sport, he or she is less likely to fall as often and also more likely to attempt, as part of advancing their skills, acrobatic or aerial maneuvers, or both, that may put them at risk for other injuries.

Use of protective equipment for the wrist is a method for prevention of injury. The most compelling evidence is found in the two randomized control trials that studied the protective effect of wrist guards. Both demonstrated a statistically significant reduction in wrist guard injury in the guarded group, compared with the unguarded.

Our search found numerous studies that looked at the effect of wrist guards; however, there was no consensus on which particular type of wrist guard would be most effective. The majority of the studies that we reviewed did not mention a brand name or a description of the type of wrist guard that was used by participants. Given the wide array of wrist guards on the market, it is important to know the type and material of a wrist guard when trying to study the effectiveness of a product.

There were also several studies that looked at the biomechanical aspect of wrist guards. Each study used a different setup to simulate a fall and measure the force on the lower arm. Live human subjects, cadavers, and an EAI arm were used to measure the forces occurring with falls. The simulation of falls can only be generalized, because it is very difficult to imitate the environmental factors seen on a snow covered mountain, and the precise orientation of the forearm-wrist when a subject falls. There were also various wrist guards-materials used in all these studies, with no mention of the availability of these products to the consumer.

The evidence of the protective effects of wrist guards will not be effective in preventing injuries unless snowboarding participants use them during sport activity. Many of the studies found low usage of wrist guards by participants. Some issues to consider are the aesthetics of the wrist guards, social acceptance, fit of the wrist guard, and availability.

There is also concern for injuries sustained due to the wrist guard itself. Cheng and associates did a case report on "splint top" fractures sustained by rollerbladers wearing wrist guards. All cases had fractures seen near the proximal border of the wrist splints. There were no studies found in our literature search about cases with fractures due to snowboard wrist guards. (34)

Conclusion

This study provided multiple literature findings that support the high prevalence of wrist injuries in the snowboard population, as well as the protective effect of wrist guard use. It is important to understand that these studies did not provide a consensus on the effectiveness of any one particular wrist guard type. Further research is required to determine the degree of effectiveness of wrist guards that are currently available to consumers.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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Suezie Kim, M.D., and Steve K. Lee, M.D.

Suezie Kim, M.D., is a Resident in the Department of Orthopaedic Surgery, and Steve K. Lee, M.D., is Associate Professor of Orthopaedic Surgery, New York University School of Medicine, and Associate Chief, Division of Hand Surgery, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center, and Co-Chief, Hand Surgery Service, Bellevue Hospital Center, New York, New York.

Correspondence: Suezie Kim, M.D., NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 East 17th Street, Room 1402, New York, NY 10003; suezie.kim@nyumc.org.
Table 1 Summary of Prospective Randomized Controlled Studies

                                              Wrist Guard
Study                  Study Population       Design

Machold et al. (24)    721 Austrian           Wrist guard
                       students, 342          prototype: palmar,
                       protected vs 379       curved at carpus,
                       unprotected            distal end did not
                                              exceed proximal
                                              flexion crease of
                                              hand, extension
                                              proximally to
                                              forearm

Ronning et al. (22)    5029 participants      D-ring wrist brace
                       at Hafjell Alpine      (Smith & Nephew,
                       Center in Norway,      Nesbru, Norway),
                       2515 protected vs      aluminum splint on
                       2514 unprotected       volar side

                       Wrist Injury           Wrist Injuries
Study                  Definition             Sustained in Study

Machold et al. (24)    Abbreviated Injury     Severe wrist injury
                       Scale                  incidence: 1 of
                                              342 snowboarders
                       --minor injuries:      in protected
                       contusions, sprains    group, 9 of 379
                                              snowboarders in
                       --moderate injuries:   unprotected group
                       fractures of radius

                       --severe injuries:
                       displaced fractures
                       of radius

Ronning et al. (22)    Wrist sprains and      1.2% unprotected
                       fractures              group sustained
                                              wrist injury vs
                                              0.3% protected
                                              group

Study                  Results

Machold et al. (24)    --Risk decreased by
                       factor of 0.13 with
                       protector (p = 0.05)

                       --Risk decreased
                       by factor of 0.83
                       for each half day
                       of accumulated
                       experience

Ronning et al. (22)    Frequency of wrist
                       injury protected
                       vs unprotected
                       significant (p =
                       0.001)

Table 2 All Other Studies

                                Study             Wrist Guard
Study         Study Type        Population        Design and Use

Russell et    Meta-analysis     Six studies,      N/A
al. (25)                        including
                                randomized
                                controlled
                                trials, cohort
                                studies, and
                                case control
                                studies

Kroncke et    Cross sectional   226               --16.7% of
al. (29)      survey            snowboarders      snowboarders
                                of the 333        used wrist
                                adolescents       guards.
                                surveyed in
                                skate park, ski   --No mention
                                lodge, high       of wrist guard
                                school, and       design
                                lake front in
                                central and
                                southeast
                                Wisconsin

                           Wrist
              Wrist        Injuries
              Injury       Sustained
Study         Definition   in Study    Results

Russell et    N/A          N/A         --77% decrease in risk of
al. (25)                               wrist injuries with wrist
                                       guard use (RR: 0.23,
                                       95% CI, 0.13-0.41)

                                       --71% decrease risk of
                                       wrist fractures with wrist
                                       guard use (RR 0.29,
                                       95% CI, 0.10-0.87)

Kroncke et    N/A          N/A         --Parents most common
al. (29)                               reason for use of any
                                       protective equipment
                                       (35%).

                                       --Rule-requirement
                                       (23%), friends (20%),
                                       sibling (5%), coach
                                       (4%), celebrity-
                                       advertisement (3%), and
                                       physician (3%)

Table 3 Summary of Prospective Case Control Studies

                 Study                                 Design Of Wrist
Study            Population         Wrist Guard Use    Guard

Hagel et al.     1066 injured       --1.6%             No mention
(23)             snowboarders vs    snowboarders
                 970 control in     with upper
                 19 of largest      extremity
                 ski areas in       injuries wore
                 Quebec (one        wrist guards
                 season)
                                    --3.9%
                                    snowboarders
                                    with other
                                    injuries wore
                                    wrist guards

Idzkowski et     7430 snowboard     5.6% injured       No mention
al. (13)         injuries vs        snowboarders
                 3107 non-          wore wrist
                 injured            guards
                 snowboarders at
                 47 medical
                 facilities near
                 Colorado ski
                 resorts (10
                 seasons)

Langran et       2124 snowboard     --No first-day     No mention
al. (26)         injuries vs        participants
                 1782 control at    wore wrist
                 three ski areas    guards
                 in Scotland
                 Cairngorm,         --1.3% of all
                 Glenshee, Nevis    other injured
                 Range              snowboarders
                                    wore wrist
                                    guards

Machold et       152 injured        39% of all         Mention of
al. (15)         snowboarders vs    snowboarders       gloves with
                 2579 controls      wore wrist         integrated
                 in Austria,        guards             wrist guards
                 during winter                         available on
                 sport week from                       market, but not
                 86 schools (one                       specified in
                 season)                               association
                                                       with injury

Made et          568 snowboard      --11% injured      No mention
al. (16)         injuries at        snowboarders
                 Tarnaby and        wore wrist
                 Hemavan ski        guards
                 resorts, Sweden
                 (10 seasons)       --19% advanced
                                    group vs 10%
                                    intermediate
                                    group vs 7% in
                                    beginner group
                                    wore wrist
                                    guards

Matsumoto        6837 snowboard     --16% of all       No mention
et al. (5)         injuries           injured
                 presented to       snowboarders
                 Sumi Memorial      had protective
                 Hospital,          equipment
                 serving more
                 than 10 ski        --87% injured
                 resorts in         snowboarders
                 Okumino area of    did not
                 Gifu, Japan, vs
                 3 million
                 snowboard
                 participants as
                 controls (5
                 seasons)

O'Neill et       2355               N/A                In-line skating
al. (27)         participants in                       wrist guard by
                 the White                             Seneca Sports
                 Mountains of                          Inc.
                 New Hampshire,
                 Learn to
                 Snowboard
                 program, 551
                 protected vs
                 1804
                 unprotected

Slaney et        119 injured        --15%              No mention
al. (28)         snowboarders       snowboarders
                 with wrist         with wrist
                 fracture vs 375    fractures wore
                 controls at        wrist guards.
                 Mount Buller
                 Medical Centre,    --20% control
                 Victoria,          snowboarders
                 Australia (one     wore wrist
                 season)            guards

                 Wrist Injuries
                 Sustained in       Wrist Guard
Study            Study              Effectiveness

Hagel et al.     26% of all         Wrist guard use
(23)             injured            reduced hand-
                 snowboarders       forearm wrist
                 had a wrist        injury by 85%
                 injury             (95% CI, 0.05-
                                    0.45)

Idzkowski et     21.6% of all       Injured
al. (13)         snowboard          snowboarders
                 injuries were      without wrist
                 in the wrist       guards were
                                    twice as likely
                                    to be seen for
                                    a wrist injury
                                    as those who
                                    wore guards
                                    (p = 0.0001)

Langran et       --33.3% first-     N/A
al. (26)         day
                 participants
                 injured wrist

                 --21.2% all
                 other
                 snowboarders
                 sustained wrist
                 injury

Machold et       32.2% of all       Lack of use of
al. (15)         injured            wrist guards
                 snowboarders       increased risk
                 had a lower        of injury by
                 arm-wrist          2.78 (95% CI,
                 injury             1.05-7.35, p =
                                    0.039)

Made et          35% of all         N/A
al. (16)         snowboard
                 injuries
                 involved wrist,
                 lower arm

Matsumoto        --40% of all       N/A
et al. (5)         snowboard
                 injuries were
                 upper
                 extremity,
                 compared with
                 19% in skiing
                 (p < 0.001)

                 --62% of all
                 snowboard
                 fractures in
                 upper extremity
                 were wrist
                 fractures
                 (p < 0.001)

O'Neill et       --2.2%             Frequency of
al. (27)         unprotected        wrist injury
                 group sustained    protected vs
                 wrist injury       non protected
                                    significant (p
                 --0% in            < 0.001)
                 protected group

Slaney et        24% of             Use of wrist
al. (28)         snowboarders       guards
                 included in        demonstrated
                 study had a        42% reduction
                 wrist fracture     in wrist
                                    fracture,
                                    though not
                                    statistically
                                    significant

Table 4 Summary of Biomechanical Studies

                               Experimental
Study            Study Type    Subject          Wrist Guard Design

Greenwald        Cadaveric     Six pairs        --Wrist guard
et al. (30)                    fresh-frozen     constructed of Kydex
                               cadaveric        (Kleerdex Corp.,
                               arms             Mount Laurel, New
                                                Jersey), with
                                                ventral splint from
                                                metacarpophalangeal
                                                joint to mid-
                                                forearm; secured
                                                with three Velcro[R]
                                                straps (Velcro[R]
                                                USA Inc.,
                                                Manchester, New
                                                Hampshire)

Hwang et         Human         30               Bone Shieldz
al. (31)         subject       participants,    (Litchfield,
                               in cable-        Illinois)
                               released fall
                               testing set-up

Kim et           Mechanical    Enhanced         --Generic brand
al. (32)         surrogate     air bag          guard (UltraWheels,
                               interaction      First Team Sports
                               arm (EAI)        Inc, Anoka, Minn)

                                                --Sorbothane glove
                                                (Ergotech Canada
                                                Inc, Ontario, Ca)

                                                --Air cell (Aircast
                                                Inc., Summit, NJ)

                                                --Air bladder
                                                (Dielectrics
                                                Industries,
                                                Chicopee, Mass)

Staebler et      Cadaveric     Three pairs      Guard A: Bone
al. (33)                       fresh-frozen     Shieldz (Litchfield,
                               cadaveric        Illinois)
                               upper
                               extremities      Guard B:
                                                Rollerblades
                                                (Minnetonka,
                                                Minnesota)

                 Design of          Simulation of
Study            Simulation         Fall               Results

Greenwald        Drop fixture,      Specimen dropped   --Increase in
et al. (30)      with specimen      at height of 40    impulse applied
                 secured to         cm onto force      by force
                 mounting stage;    platform           platform to
                 fixture placed                        forearm before
                 over a force                          failure in
                 platform (AMTI                        braced group
                 Corp.,                                (p < 0.01).
                 Watertown,
                 Massachusetts)                        --Wrist guard
                                                       use may have
                                                       some
                                                       prophylactic
                                                       effect in low
                                                       energy falls but
                                                       not at higher
                                                       loads

Hwang et         --Landing plate    Subject leaned     --Only
al. (31)         mounted on         forward or         significant
                 inclined wall      backward using a   change with
                 (20[degrees]       control cable;     wrist guard use
                 from vertical)     on cable           was impact force
                 --A force          release, subject   parameter of
                 transducer         used both hands    backward fall
                 measured impact    to stop fall
                 and braking        onto landing       --Wrist guards
                 force              plate              did not provide
                                                       statistically
                                                       significant
                                                       reduction of
                                                       maximum force
                                                       transmission

Kim et           Guillotine style   Mechanical         --Radius
al. (32)         platform with a    surrogate          fracture at 2245
                 vertical slider-   dropped at four    N force
                 drop fixture       different
                 placed over a      heights (13, 25,   --All padded
                 commercial force   38, 51 cm) with    conditions had
                 plate (Type        five different     smaller peak
                 4600-10, Bertec,   conditions         impact forces
                 Columbus, Ohio),   (bare, generic     than the bare
                 and forearm load   wrist guard,       hand (p < 0.05)
                 cell               Sorbothane
                                    glove, air cell,   --Wrist guard
                                    air bladder)       became
                                                       ineffective at
                                                       height of 51 cm

Staebler et      --Servohydraulic   Load applied a     --Dorsal distal
al. (33)         materials          volar pole         radius strain:
                 testing machine    scaphoid and       wrist guard A
                                    fall contact       46% less than
                 --Bone strain      position           unguarded, wrist
                 measured in                           guard B 23% less
                 distal radius,                        (both p < 0.05)
                 distal ulna,
                 midshaft of                           --Volar distal
                 radius                                radius strain:
                                                       wrist guard A
                                                       80% less (p <
                                                       0.05), wrist
                                                       guard B 30% less
                                                       (not stat
                                                       signif)

                                                       --Dorsal
                                                       midshaft strain:
                                                       wrist guard A
                                                       61% less (p <
                                                       0.05), wrist
                                                       guard B min
                                                       difference

                                                       --Volar midshaft
                                                       strain: wrist
                                                       guard A 61% less
                                                       (p < 0.05),
                                                       wrist guard B
                                                       min difference
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